MINUTES OF THE
SENATE COMMITTEE ON HUMAN RESOURCES AND FACILITIES
Sixty-seventh Session
June 14, 1993
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 2:00 p.m., on Monday, June 14, 1993, in Room 119 of the Legislative Building, Carson City, Nevada. This hearing was teleconferenced to Cashman Field Center, Room 207, Las Vegas, Nevada. Exhibit A is the Meeting Agenda. Exhibit B is the Attendance Roster.
COMMITTEE MEMBERS PRESENT:
Senator Raymond D. Rawson, Chairman
Senator William R. O'Donnell, Vice Chairman
Senator Randolph J. Townsend
Senator Joseph M. Neal, Jr.
Senator Bob Coffin
Senator Diana M. Glomb
Senator Lori L. Brown
GUEST LEGISLATORS PRESENT:
Assemblywoman Marcia de Braga, District No. 35
STAFF MEMBERS PRESENT:
Judy Alexander, Committee Secretary
Gary Crews, Legislative Auditor
Pepper Sturm, Research Analyst
OTHERS PRESENT:
Robert E. Dickens, Ph.D., Director, Office of Government Relations and Economic Development, University of Nevada, Reno
Hamilton D. Moore, Attorney, Las Vegas
Nancy Patnaud, Victim, Las Vegas
Sue McGonegal, Victim, Las Vegas
Deborah Schlotfeldt, Victim, Las Vegas
David Gay, Social Worker, Clark County
Kevin R. Christensen, Acting Director, Office of Protection and Advocacy, Department of Commerce, State of Nevada
Neal Curry, C.E.O., Truckee Meadows/Willow Springs Hospital
Tom Bittker, M.D., Medical Director, Truckee Meadows Mental Health Services
Harold. S. Orchow, M.D., Medical Director, Montevista Hospital
Bruce L. Tanenbaum, M.D., President, Northern Nevada Association of Psychiatric Physicians
Jerry Zadny, Ph.D., Administrator, Mental Hygiene and Mental Retardation Division, State of Nevada
James L. Wadhams, Lobbyist, Nevada Hospital Association
Brian Luck, Student, Las Vegas
Sandy Coyle, Parent
Jeanne Simons, Parent
John E. Adkins, Deputy Treasurer of Operations, State of Nevada
John Sarb, Administrator, Division of Child and Family Services, State of Nevada
Chairman Rawson opened the hearing on Assembly Bill (A.B.) 589.
ASSEMBLY BILL 589: Requires board of regents to establish program of student teaching & practicum.
Assemblywoman Marcia de Braga, District No. 35, spoke in support of A.B. 589. She explained, this bill requires the university system to establish an outreach program with all school districts in Nevada, for the purposes of student training, student teaching and practicum. This would reduce the cost to students, if they are able to fulfill these requirements in their home counties.
Chairman Rawson asked, is there someone in particular who has an interest in this. Assemblywoman de Braga responded, in her district, there are several people who are commuting students, who wanted to be able to fulfill requirements, in their home county. This program is in place in some areas and A.B. 589 would require it to be offered in all areas, by the university system.
Assemblywoman de Braga responded to a question from Chairman Rawson and said, this is only for the University of Nevada System. She stated, there is another bill that allows other post-secondary accredited courses to enter into the same kinds of agreements. Chairman Rawson noted, the senate passed a bill in this session that would allow that, but A.B. 589 would create a conflict. Assemblywoman de Braga explained, A.B. 589 has a sunset provision and she does not see a conflict. Other post-secondary schools are already doing this, and want this bill passed, so what they are doing would be legalized. She explained that sunseted means, pending accreditation of the accreditation process.
Chairman Rawson asked, Assemblywoman de Braga, would she have any objection, if this is opened up to other programs in neighboring states or private schools that meet certain standards. Assemblywoman de Braga responded, no.
Assemblywoman de Braga explained, the bill originated from complaints from student teachers, from Churchill and Pershing counties, who had to commute daily to Reno. She stated, Dr. Dean Myers, University of Nevada, Reno, testified in favor of A.B. 589 in the assembly.
Robert E. Dickens, Ph.D., Director, Office of Government Relations and Economic Development, University of Nevada, Reno (UNR), explained A.B. 589 is a general policy statement, of which UNR is in support. He stated, Dr. Dean Myers, College of Education, UNR, feels the bill is compatible with what University of Nevada, Las Vegas is doing. He responded to a question from Senator Glomb and advised, many of the county school districts already have relationships established with both of the Colleges of Education, for the provision of programs, such as this. The problem that led to drafting this legislation, simply had to do with one practicum that is federally funded. In order to receive the federal funds, the practicum had to be offered in a school, which had racially and ethnically mixed and lower income students. Generally, the supervision of a practicum is delegated to a principal or administrator in a rural county school district, to provide the oversight necessary for student teachers or others who are seeking additional education.
Chairman Rawson asked, is it necessary to have legislation on this or can it be worked out informally. Mr. Dickens responded, A.B. 589 is a policy statement and in support of the universities' mission.
Mr. Dickens responded to a question on S.B. 218 and explained there is a amendment which Sierra Nevada Community College and the university agreed to and are waiting for it to come back from the printer and added, there is no remaining conflict over that, at this point in time.
Chairman Rawson asked, if this bill were not to be processed further, could the arrangements still be established without the bill. Mr. Dickens responded, yes, it reflects current practice.
Chairman Rawson closed the hearing on A.B. 589.
Chairman Rawson opened the hearing on Senate Bill (S.B.) 533.
SENATE BILL 533: Makes various changes to provisions governing admission to and hospitalization in mental health facilities and hospitals.
Senator Lori L. Brown, District No. 7, explained that a number of people spoke with her about a similar problem. They described going into a psychiatric hospital for minor counseling, suddenly they found themselves locked up and were not permitted to leave until their insurance ran out. She introduced the bill before working out any specific language changes and offered those changes as amendments.
Chairman Rawson brought to the attention of the committee Proposed Amendments (Exhibit C) from Washoe Legal Services. He also offered for the record, a letter appearing to be in opposition to the bill from R. Dale Reynolds, CEO/Administrator, Montevista Hospital, Las Vegas, Nevada (Exhibit D). He advised to date, there is a record of 21 telephone responses in favor of the bill.
Hamilton D. Moore, Attorney, Las Vegas, explained, Deborah Schlotfeldt contacted him 4 years ago advising him that she had been held against her will by Charter Hospital, Las Vegas. In the course of the investigation of her case, many similar incidents were discovered. He pointed out, incidents such as Ms. Schlotfeldt's, have become a national problem and are created by the current legislative scheme, which allows a private psychiatrist to lock up someone, without a judicial hearing, for a period of 14 days. He stated, this same psychiatrist can charge between $150 to $300 dollars a day in alleged services, that he would provide to a patient while they are locked up. Charter Hospital has collected between $500 to $700 dollars per day for various alleged services. He pointed out, advertising on television creates an incredible market for private mental health facilities, as well as attorneys and car lots. He explained, the difference between a psychiatric hospital, an attorney and a car lot, is that a person can tell the salesman he does not want to buy the car or does not want the attorney's services. However, a person cannot leave Charter Hospital or at Montevista, unless they say so. If the person has insurance, that factor can frequently add a substantial period of time to the incarceration. He referred to a document, Committee Against Psychiatric Prisons for Profit (Exhibit E), Exhibit 1, which shows a Las Vegas Review Journal editorial indicating that something seriously needs to be done about this problem. He noted, Nevada is one of a few states, which allows people to be incarcerated at the whim of a private psychiatrist, for as long as 14 days. He added, that 14 day stay, may cost between $12,000 and $14,000, for which the patient would be responsible, if the insurance company would not pay,
Mr. Moore pointed out, this same situation exists in Texas, where Charter hospital was operating and read from Exhibit E, Exhibit 2. He then read the language in the petition.
The state of Texas brings this suit, in the public interest to address extensive allegations regarding corruption, which feeds upon the weaknesses of individuals, who look to people in white coats for succor, but who end up being suckered by a psychiatric hospital industry, intent upon making a profit at everyone else's expense. The victims of their ruthless profit making schemes, included persons who have been previously victimized by violent criminals. Thereafter, such victims are further victimized by individuals with medical degrees or some other seemingly important accreditation, who have sold the soul of their professions to corporations for money.
Mr. Moore gave a description of how the private mental health industry operates in Las Vegas, which is based upon his experience through interviews of numerous people in the profession, interviews of more than 100 victims and upon extensive reading. He explained, there is a situation, which is biased from the outset, towards the eventual incarceration of these people and the extraction of money from their insurance proceeds. He referred to Exhibit 3 (Exhibit E) to the Charter Challenge. In item number 13, page 6, of Exhibit 3 (Exhibit E), cash bonuses are given to all employees, when Charter Hospital of Las Vegas makes a 100 percent occupancy, (84+ patients) at midnight. The Charter Challenge is a incentive based employee marketing program, which purpose is to share the financial success of Charter Hospital of Las Vegas with its employees. He stated another provision pays up to $25, if an employee manages to talk an individual out of leaving Charter Hospital, against medical advice. He commented, as a result of publicity, he thought this program has been dropped, but stated, the same problem still exists.
Mr. Moore explained, victims are interviewed by sales people, not trained medical people, upon arrival at these psychiatric hospitals, who are extremely biased towards what is called a conversion ratio. The employment of these sales people, is covertly contingent upon converting enough people who come to the premises into in-patients, so that the high profit margins of the various private mental health institutions, in the state of Nevada can be maintained.
Mr. Moore commented, later decisions are going to be made, upon the initial information obtained from the patient, which is somewhat biased. In the commitment process, that decision can be made by any physician in this state and that physician stands to get $200 to $300 dollars per day from the commitment, from the person, as long as they can keep the patient in the psychiatric hospital.
Mr. Moore stated, the doctors are selected and placed upon a call list. All of the private mental health hospitals have them and it is quite an advantage to be placed on this hospital call list. Through calculations based upon 50 percent occupancy, Charter Hospital would have approximately $280,800,000 in fees to hand out every year. He said, the way they do that, is by selecting the doctors to whom they will refer cases. It is his belief, this is used to select the physicians.
Mr. Moore stated, once a patient is in the psychiatric hospital, there is an incredible incentive for doctors to admit a patient, so called voluntarily. He referred to one case in which a patient was invited in the back room to look around and then she was denied exit. The other patients will be admitted voluntarily and when the patient asks to leave, the hospital staff advises the patient, that if they check out against medical advice, the insurance will not pay for their stay at the hospital. He pointed out, in every case they investigated, where patients demanded to be discharged and were going against medical advice, the insurance companies did pay. He stressed, there have been false misrepresentations made, in order to keep victims in a hospital at this rate of $800 to $900 per day total.
Mr. Moore said, if the patient makes loud demands to be released, the patient is told they will be tied up, which is another restraint towards their departure.
Mr. Moore pointed out, the Committee Against Psychiatric Prisons for Profit (CAPPP) would like to see that Nevada's citizens, who come into contact with a private mental health facility, in this state, have some of the rights that a criminal would have, if he were arrested by the police. He referred to the 30 year anniversary of the decision in Miranda verses Arizona, which requires that people who are arrested by the police, be informed of their rights. CAPPP believes there would be a great deal of benefit, if private mental health institutions would be required to provide the same kind of warning above their door and simply say that once a person comes in, he cannot leave, unless that facility says so.
Mr. Moore pointed out, criminals are provided a right to counsel. People who are seeking help from mental health facilities, who have not committed a crime, are locked up at the rate of $800 to $900 per day. Most of these patients cannot afford to hire an attorney and the statutory scheme does not provide an adequate way to get them out. CAPPP feels it would be appropriate for attorneys to be provided to these people, within the first 2 or 3 days of their institutionalization. Finally, CAPPP feels it would be extremely appropriate that expert witness fees be paid for by the private mental institution and that an absolute, unquestioned right to an examination by a psychiatrist of the persons own choosing, be granted. If the psychiatrist would determine the person did not need to be there in the hospital, then the person would be immediately discharged. CAPPP feels it would be appropriate to have a judicial hearing within a minimum of 72 hours, instead of the present time of 14 days.
Mr. Moore stated, crisis teams have been developed from the various private mental health facilities. The term crisis team is a misnomer, because they will not participate in a crisis situation. He gave an example of a man trying to kill himself with a gun, and explained, the crisis team waited for the police to disarm the person, then responded to the situation, verified the person had appropriate insurance coverage and then took the person to the private mental health facility. He commented on a case before the Nevada Supreme Court, where a husband became disgruntled with his wife. The husband called a crisis team and told them the wife was suicidal. The crisis team responded, verified the insurance coverage and then took her away. The husband used the time to help himself to the bank accounts, took the children and vacated himself from the situation.
Mr. Moore advised, through their investigation, they discovered services that had been billed for, which were not given and regular bills for long cycle therapy sessions from the doctor, when they were very short visits. Classes were billed for $90 per hour per patient in areas such as nutrition.
Mr. Moore stated, once a person is incarcerated, there is the situation where they are involuntarily administered drugs. Many of the victims have lost their job due to being incarcerated for a long period of time. Now, these victims find that medical insurance is harder to get, because they have this ominous pre-existing condition. Jobs are harder to get because employers are reluctant to hire them. Promises were made by the staff of the psychiatric hospital, that their insurance would pay for their entire stay. In some cases, this was not true, and now the victims are relentlessly pursued by the collection agencies of these various institutions. Once a person has been admitted to an institution, it becomes easier for them to be admitted again. This was the problem with the man and his wife referenced earlier. She had been previously admitted to a mental institution, and therefore the second time was much easier.
Mr. Moore stated, when the facility commits a person by filing a petition with the court, the file becomes a matter of public record. Anyone could then read what a person's psychiatric problems are and the incarceration will show up on the person's credit report.
Mr. Moore stated, S.B. 533 seeks to remedy these problems in several ways. Section 2 of the bill requires immediate notice to the Office of Protection and Advocacy. Section 4 provides for legal assistance when a person is incarcerated, if the person wants it, at the expense of the private mental health hospital. He stated, in addition, that section should include the cost of the psychiatric review. Page 4 of the bill requires immediate discharge. He pointed out, frequently the victim would ask to leave and would be advised that he/she have to wait until their doctor returns from Hawaii, etc. S.B. 533 requires that the person be discharged within 15 minutes. The provision in paragraph 2, section 12, provides that individuals who are admitted under this section, need not pay for the bills that are generated, unless they agree to, after they are discharged. He pointed out, all victims who were admitted had a serious amount of insurance to cover the expenses. Paragraph 2, section 12 would cover the situation where the victim was told by the private mental institution that they have insurance and that turns out not to be true. In addition, the records are sealed in section 13, lines 7 and 8.
Mr. Moore concluded by saying, "The primary thing that has to be done is to provide people who go to mental health facilities, some sort of insurance that their liberty is not being unduly restrained for the profit motive of individual corporations and physicians.
Senator O'Donnell asked Mr. Moore, if he had talked with the attorney general, in regard to these problems with Charter Hospital. Mr. Moore responded, yes, the attorney general had been requested to investigate these matters and Mr. Moore has not received a response. It had been pointed out to the attorney general, that what had been done by the Texas attorney general Exhibit 2 (Exhibit E), resulted in a $350,000,000 judgement in favor of the Texas attorney general, for the violations of human rights. It is his understanding, the attorney general did not feel there was time and resources to undertake this.
Nancy Patnaud, Victim, Las Vegas explained to the committee her feelings of not wanting to wake up the next morning, and realizing
she needed assistance. She had seen commercials on television for Charter Hospital, which said if you do not get help there, get help somewhere. She felt that said they were open, that Charter Hospital had a lot of different programs and would be receptive to what she needed. She planned to check out several mental health facilities, to see if they had group sessions or one-on-one counseling. When she arrived at Charter Hospital, she was interviewed by two people, one of whom recommended she have the 21 day stay at Charter Hospital. She explained to the staff that she could not stay due to a job. She told the staff there were other counseling centers closer to her home and asked to see the facility, in case she changed her mind. At the end of the tour of the facility, she was trapped by several people. When she asked what were her options, the staff advised her, she could go to Desert Springs Hospital and be examined by a doctor there. If that doctor determined that she was okay, then she could leave. She took the option and was escorted to Desert Springs Hospital. A man from Charter Hospital was there to meet her and asked the same questions that she had answered earlier at Charter Hospital. He advised her, he thought their 21 day program would benefit her and she was escorted back to Charter Hospital. After being there 3 or 4 days, she was advised, if she signed in voluntarily, she could leave within a few days. After she signed in, she was advised when someone signs out, the insurance would not pay and the hospital would set a court hearing date to determine her sanity, whether or not she would be able to leave at all. She was not released for 18 days. She was told, if she did not have insurance, she would be sent to the state mental facility, where she would not be allowed out. She was told, if she left their facility, the police could arrest her and take her back to the hospital. She explained, she lost her job, had to file bankruptcy and is still going to counseling, because of some of the things that happened at Charter Hospital. In her opinion, this is against human rights to be able to do this to somebody and have it to be legal.
Chairman Rawson asked Ms. Patnaud, had she ever admitted herself or been admitted to a psychiatric facility. Ms. Patnaud responded, no. She explained, 10 years earlier, she went to counseling for something in her past, which had no bearing on her purpose for going to Charter Hospital.
Chairman Rawson asked Ms. Patnaud, did she feel there was a crisis when she went to check out these facilities. Ms. Patnaud responded, absolutely not, that is why she went there, so it would not become a crisis. She explained, after she was released from Charter, there was definitely a problem.
Senator Glomb asked Ms Patnaud, did she see a physician during her stay at Charter Hospital. Ms. Patnaud responded, she did not see one for 2 or 3 days and was in solitary for 7 days. Dr. Lake suggested that she sign in voluntarily so she could leave in a few days. She found that not to be true, because the doctor who was assigned to her case was in Hawaii, and she could not be released until he returned. When he did return, she saw him for 2 or 3 minutes at a time, which was all the counseling she received from him.
Senator Glomb asked Ms. Patnaud, if she was on an involuntary hold from the beginning of her stay at Charter Hospital. Ms. Patnaud stated, in her record at Charter Hospital, it said she had planned suicide for 6 months, that she had paid for a funeral and that she had written a suicide note. She stressed, none of this is true. The hospital put her on a 72 hour hold, and later placed a court hold on her until 14 days later, because of the attempted suicide. She explained, she signed in 6 days after her incarceration, so she would not have to go to court. She had been told by other patients who had gone to court, this had extended their stay up to 90 days, at the hospital.
Senator O'Donnell asked Ms. Patnaud, how much time had she been attended to by a physician, at Charter hospital. She explained, she had been seen by a psychologist 30 to 40 minutes every other day in the beginning and every day in the second week. She stated Dr. Brewer, Psychiatrist saw her approximately 15 minutes total and Dr. Lake saw her approximately 2 hours in 18 days.
Senator O'Donnell asked Ms. Patnaud, did she attend group therapy during her stay at Charter Hospital. She stated, there are classes the patients must attend each day, such as happy classes, grieving classes, etc.
Ms. Patnaud stressed, her insurance company was billed almost $13,000, she was billed $3,000 and the way the law is currently written, mental health facilities are allowed to hold people against their will.
Senator Brown asked Ms. Patnaud, how closely did her release coincide with when her insurance ran out. Ms. Patnaud responded, on the morning of the eighteenth day, she was advised by the staff of Charter Hospital she could leave and that it would look better if she would stay until afternoon. This was the day her insurance ended. She departed at 12:05 p.m. and was charged for the balance of that day.
Sue McGonegal, Victim, Las Vegas, explained that her incarceration
began December 26, 1991, after the Charter Hospital crisis evaluation team came to her home, at the request of her husband. The crisis team advised her husband that a 72 hour observation would be necessary. She did not want to go to the hospital and was forcibly taken from her home. Upon arrival at Charter Hospital, Dr. Scott Rubin, who had been her physician 6 months prior for a tranquilizer addiction, was assigned as her physician. The previous admittance to Charter Hospital for tranquilizer addiction, required a 28 day stay at a cost of $13,000 which, in her opinion, Dr. Rubin did not help her. She stated, Dr. Rubin left for vacation 1 day after her admittance and did not return until January 13, 1992. He signed to have her committed before he left for vacation. She pointed out, her family was not advised of her being committed. Her insurance company paid over $17,000 for this incarceration.
Ms. McGonegal explained, because she was labeled suicidal she was prohibited from activities. She attended one women's group meeting, at the cost of $115.00, which was considered group therapy. She witnessed one volleyball game and was billed $115.00 again for group therapy. Her itemized bill listed 399 medications given to her during the 18 day incarceration, most of which were central nervous system depressants. She reminded the committee of her treatment for addiction to tranquilizers at Charter Hospital, under the same physician 6 months prior. When she asked for help from the staff at Charter Hospital, she was advised, her doctor was out of town and she would have to wait until January 13th when he returned. She did not receive counseling, but was visited by a licensed social worker periodically. It stated in the brochure for the hospital that a family gathering would take place once a week, to talk about problems and this did not take place once during her incarceration. The day she was released, her only contact with Dr. Rubin was a hand shake and she was billed $130.00 for a consultation with him.
Deborah Schlotfeldt, Victim, Las Vegas, stated 4 years ago, after viewing commercials on television, she called Charter Hospital and was invited to come in and talk. Upon arrival, her insurance was checked out first and then she was invited to stay the night and see what the hospital had to offer. She returned home to get an okay from her husband and then returned to the hospital with an overnight bag. She was awakened the following morning, by uncontrolled screaming, and discovered she was locked up in a "psycho" ward. The staff advised her the only person who could release her was her doctor. She was not aware a doctor would be involved and demanded to speak to the doctor immediately, advising them, there has been a terrible mistake made. After speaking to the doctor for 5 to 10 minutes, the doctor advised her, since she has a history of breaking marriage counseling appointments, she would stay at the hospital and her husband could come inside and get the counseling that they need. In the meantime, her husband's job with the railroad, took him out of town for several days. She went to the front desk and demanded to speak to the head of the hospital or the person who had admitted her. When the staff asked the doctor for her release, he advised them, Ms. Schlotfeldt was suicidal and should not be released. Ms. Schlotfeldt made several phone calls trying to find someone to help her and was unable to secure an attorney due to the fact it was Sunday. Her husband arrived back in town on Tuesday, told the staff his wife did not have to stay there if she did not want to and the hospital immediately released her.
David Gay, Social Worker, Clark County, referred to Ms. Schlotfeldt's case and said, the first area S.B. 533 would change is this kind of incarceration restricting a person's freedom. The bill would entitle the person to a second opinion, which could be a physiatrist or a member of the crisis unit at the public hospital. He explained, the public hospital in Las Vegas is triaging people, who have health insurance policies, to these private secular hospitals, and stated, they do not have statutory or regulatory right to do this. He said, the public psychiatric unit is operating on a 24 hour basis and in place. As long as it is acting as a shield for the private hospitals now, why couldn't they provide that second opinion on those rare occasions when the private hospitals say that someone has a complaint.
Mr. Gay continued, the second area is the misuse of the police and the ambulance service in Clark County. Public facilities and public resources are being used to benefit private hospitals. They are being used as guards to transport these people to private hospitals. The third area is when people are evaluated by the so called private psychiatric teams. In his opinion, they should not be allowed to engage the police to do their work for them, and in effect, take part in what often is a loss of the person's rights and imprisoning the person. He pointed out, the interesting question asked over and over again in reviewing the cases is, why is it that all of these people who are debilitated, at the ragged edge or are grossly psychotic, have a viable insurance policy.
Kevin R. Christensen, Acting Director, Office of Protection and Advocacy (OPA), Department of Commerce, State of Nevada, testified in support of many of the provisions of S.B. 533, that would extend those due process protections and civil rights protections to many people in Nevada, who may feel that their detention or restraint in mental health facility or psychiatric hospital has been illegal, inappropriate, or unnecessary. He asked that the committee members be aware of the fact that anytime a person is confined against their will, or restrained from their liberty, it is our basic constitutional right to be deprived of such liberty, only by due process of law. Such due process does not exist when a person is voluntarily admitting themselves to a mental health facility or psychiatric hospital, and they are told they may not leave, based solely on the determination of one person, and not a court of law or a jury of their peers. He reminded the committee, that only in very special circumstances, one of which is mental illness and the other being tuberculosis, that a person can be deprived and restrained from their liberty in a hospital in Nevada, without order of a court.
Mr. Christensen continued, each of us have the opportunity to decide when to leave a hospital, even though we might die from a heart attack, die from cancer, die from acquired immunodeficiency syndrome (AIDS) or many other illnesses. That right is abrogated, when it is alleged that a person may have a mental illness. In the case of too many Nevadans, who have volunteered for treatment and have decided to leave that treatment, they have been told, as the committee has heard today, no, "Because we think you are too sick. Or, if you attempt to leave against medical advised, your insurance company will not pay your existing hospital charges. Or, if you remove your child from treatment, we will inform the child welfare authorities, and you may face child neglect abuse charges, Or, if you attempt to leave, we will have you court committed. Or, if you leave, no psychiatrist in this state will ever treat you again. He stated, these complaints are documented, and there are numerous actual events that have happened to people in both private and public facilities in Nevada." It is that reason, why it is so important, that the provisions of this bill that provides access to the mechanisms of protection and advocacy, of access to the Office of Protection and Advocacy, are placed into effect. Often, many people are ill advised of their rights, of their right to leave the hospital, absent appropriate due process of law, and ill advised of their right to access to advocates, attorneys and other remedies to secure their release, and their liberty.
Mr. Christensen stated, certain provisions in S.B. 533, specifically, those mandating hospitals to give notice to the Office of Protection and Advocacy, of a voluntary patients wish to leave under any circumstance. Those persons admitted or converted to an emergency admission, will most certainly improve any person's opportunity to be advised of their rights and have a qualified and trained advocate, to speak for them, to negotiate on their behalf, or bring other administrative, or legal remedies on their behalf.
Mr. Christensen stressed, he does have some concerns with S.B. 533. The language in the bill in sections 2, 6, subsections 5 and 7 of 6, and section 7, subsection 4 should be amended to include the same notification clauses to the Office of Protection and Advocacy, for persons admitted to the Division of Mental Health and Mental Retardation facilities. He stated, this would provide equal protection for both those individuals in private and public Division of Mental Health facilities. With respect to section 15, amending chapter 232 of Nevada Revised Statutes (NRS), he suggested the committee may wish to delay on this provision, depending on the outcome on Nevada's proposed reorganization act. He expressed concern, that this section also does not specifically delineate the authorities of the Office of Protection and Advocacy, in connection with the Developmental Disabilities Assistance and Bill of Rights Act, and the Protection and Advocacy for Mentally Ill Individuals Act.
Senator Glomb asked Mr. Christensen for clarification on his concerns with the bill. Mr. Christensen responded, OPA hopes the bill be amended to include those patients who are in public facilities, such as the Nevada Mental Health Institute. OPA have set problems with the sections that would potentially conflict with Nevada's proposed reorganization act. He pointed out, the Department of Commerce most likely will no longer exist under that name. He provided the committee with the suggested amendments (Exhibit F).
Chairman Rawson asked for clarification on the suggested amendment from Mr. Christensen on section 2. He asked, if a person is detained in a private mental health facility, are you saying that this should be changed to private or public health facility. Mr. Christensen responded, he suggests the term, if a person is detained in a division or private mental health facility. Section 6, subsection 5, if a person is admitted to, he would add the word division or private mental health facility. Section 6, subsection 7, if a person is admitted to a division or private facility. He stated concern in section 7 with the term clinician, due to clinicians being ill defined under NRS. He stated, that should be a psychiatrist, physician or certified psychologist.
Mr. Christensen cautioned in terms of Nevada's proposed reorganization act, in section 15 and 16, the duties of the OPA are not defined in these particular sections. In section 16 a subsection H could be added, which would say, any agency established by executive order of the Governor and assigned to the department for purposes of administrative supervision. He stated, the existing executive order does define the federal mandates, role and responsibility of the OPA. The OPA is under executive order of the State of Nevada, the executive order has been exercised and the state does have an OPA. He gave a brief history and explained, the office has existed since 1974, under the term of Developmental Disabilities Advocates Office and in 1987 was created as the OPA, adding the protection and advocacy for mentally ill individuals program, under Governor Bryan's administration. The OPA is primarily funded through federal grants for the developmental disabilities program.
Mr. Christensen stated, it is very difficult to estimate the cost to establish this bill, to predict the impact on the OPA. His office is fairly confident to take on this responsibility and mandate it under federal law to advocate on behalf of appropriate clients. He commented, OPA believes they have adequate resources available to them in reserve and could come back to the Interim Finance Committee with the approval of the administration and seek whatever accommodation they would need in their agency to meet the civil and human rights demands of their clients.
Chairman Rawson asked, is there adequate federal funding to carry on, either in the way of grants or gifts. Mr. Christensen responded, yes, and this could be augmented by other grants available in the private communities.
Mr. Christensen responded to concerns expressed by Senator Neal and stated OPA has conducted investigations, has taken appropriate administrative remedies and is preparing to take some legal remedies on behalf of some clients. The problems discussed earlier are most appropriately investigated also by the State of Nevada, Bureau of Health Facilities and the Attorney General's Office, as well as other state entities in state government.
Senator Neal asked Mr. Christensen, did the Attorney General's Office get involved in this particular situation. Mr. Christensen answered no, they were contacted, and he received secondhand information, that they had indicated, that was not under their jurisdiction.
Mr. Christensen explained, OPA is able to go in to investigate and use the services of a private attorney to bring action on behalf of their client. He clarified a question from Senator Neal and stated, OPA would not turn the investigation over to the Attorney General's Office but would turn it over to the local law enforcement. He stated, OPA turned a report over to the local law enforcement in December of 1992. They are still investigating.
Senator O'Donnell asked Mr. Christensen, why did he not approach the Attorney General's Office, since the situation has happened in both northern and southern Nevada, making it a statewide problem. Mr. Christensen stated, the attorney general is aware of these allegations. The Commission on Mental Health and Mental Retardation (MHMR) formed a subcommittee, took extensive testimony, took a great deal of time over many months in looking into these problems and attempting to resolve them and put protections into place. In his opinion, the subcommittee did a fairly good job in documenting the problems. The attorney general was represented at the meetings. Nothing has been forthcoming from the Attorney General's Office, to his knowledge, with respect to these direct problems. One of the difficulties OPA has, is that the federal mandates indicate that they can only pursue remedies on behalf of individuals, when those problems are presented to them within 90 days of discharge from the facility.
Senator O'Donnell asked Mr. Christensen, how forceful had OPA been in terms of encouraging the attorney general to get involved with this.
Mr. Christensen responded, not as forceful as they should have been. He stressed, OPA is growing more forceful in attempting to pursue remedies in the district courts on behalf of their clients.
Senator Glomb asked when did the MHMR subcommittee meet. Mr. Christensen responded, from June 1992, through February 1993. He stated, the commission reviewed problems as far back as 4 and 5 years ago.
Senator Glomb asked what was done to try and address this problem. Mr. Christensen stated, within the powers of the commission, they set into place a review mechanism of denials of rights in private for profit, private mental health facilities in the state of Nevada. Heretofore, there was no external review of any denial of rights in those facilities. Those cases will go to the commission for review, as they do in the public, division facilities, at this time.
A discussion ensued between Senator Neal and Mr. Christensen as to whom Mr. Christensen reports to, in reference to caseload, proficiency of work and statistics of results of his investigations. Mr. Christensen indicated, his position was created by executive order and assigned administratively to the Department of Commerce. He has been with the agency since 1987 and reports to Mr. Struve, Director of the Department of Commerce. He explained, within the confines of the protection and advocacy system, OPA is administratively supervised by the Department of Commerce, which would include matters of personnel and budget. He stated, actual case activity has not traditionally been within the preview of the director of the Department of Commerce and the director has not had a direct hands on responsibility for that. OPA reports the statistics of their case activity to the federal government, as well as to the advisory counsel for the mentally ill individuals program. Case activity bringing remedies, would be through law enforcement and through private legal counsel. Administrative remedies, would be though the Bureau of Health Facilities, the Department of Human Resources, and other entities within the state.
Mr. Christensen responded to Senator Neal and stated, under the Governor's executive order, as well as the Developmental Disabilities Assistance and Bill of Rights Act and the Protection Advocacy for Mentally Ill Individuals, OPA is mandated to maintain the confidentiality of their clients, as well as the confidentiality of any witnesses or informants.
Chairman Rawson suggested to the committee, discussing an amendment to see that there is a report that goes to the legislature and maybe to the director of the Department of Human Resources, and to the Governor.
Neal Curry, C.E.O., Truckee Meadows Hospital (TMH) and Willow Springs Center, Washoe County, stated if S.B. 533 is passed as it is currently stated, it will take the private physiatric hospitals out of being able to accept patients who need commitment. It would put them in a medical, legal and financial burden, based on the way it is currently written. This would, in turn, put the patients into the state system.
Chairman Rawson asked Mr. Curry, what changes would be necessary so the psychiatric hospitals can still admit the people who need help. Mr. Curry pointed out, the first problem is with the requirement that recommends or mandates the hospital furnish an attorney. He stated, it is not the hospital or mental health care workers that commits patients, it is only the state and the legal system that currently exists that can actually commit patients. He stated the second part of the concern is where it states the patient would not be responsible for the bill. That causes a problem, plus the fact where it implies, for people to come in on a voluntary basis and then the doctor feels they need to be committed. This makes for a conflict legally as well as financially and reverses the role. He suggested, if there is a proposal, he welcomes and his peers at Montevista in Las Vegas welcome any type of structure the legislature would set up that monitors this. TMH works with the OPA, and has developed patient's rights and a system where patients are notified. Patient's rights are posted in every unit next to every phone, which gives the OPA phone number. He stated, Truckee Meadows Hospital has their own internal patient advocacy program within their facilities to deal with these issues.
Chairman Rawson explained to Mr. Curry, the committee is interested in seeing that if a potential patient requests a review or requests to be out of a holding situation, that there be someone who has no vested interest, who can evaluate their request. In his opinion, the person's rights are protected, if the legislature can accomplish that. Mr. Curry responded, he agreed with that and explained how the current process works. If someone is put into a psychiatric hospital for 72 hours, they are entitled to a court hearing within 13 to 14 days. He suggested the court hearing be changed to within 72 hours after admittance. He explained, at the court hearing, the person is before a judge, plus another psychiatrist and psychologist who have not seen the patient before, and opinions are rendered at that time. He referred to how the court hearing was set up in Texas, when he was there and explained, the judges and court appointed doctors came into the facility at least once a week, so nobody ever had to wait longer than 7 days. He stated, this is another alternative that works. His concern is that normally there is an overcorrection to the problem and he feels the way the verbiage is written in this bill, that overcorrection has taken place. For the intent of protecting people's rights, he is whole heartedly behind whatever it takes to remove the controversy from the psychiatric hospitals being able to treat patients that need mental health or substance abuse services, in the state of Nevada.
Mr. Curry clarified for Senator Brown, the area of billing for involuntary incarceration. He stated, if a person is hospitalized inappropriately, by right of law for being held against their will, there are statutes in criminal court which will allow them to recoup loses, plus sue the hospital. If the person is locked up against their will, and it is deemed that is appropriate, this is where the burden falls on the hospital, according to the bill. He stated, the bill currently reads that the person is not held liable for any payment, unless they so consent to it within 14 days after discharge. In his opinion, that puts a huge burden on the treating facilities and or the psychiatrist.
Mr. Curry gave to the committee the final report from the Commission on Mental Health and Mental Retardation (Exhibit G).
Tom Bittker, M.D., Medical Director, Truckee Meadows Mental Health Services (TMMH) and an officer of a Nevada state society of psychiatric physicians and has served as Commissioner of Mental Health for Arizona. He stated, he is testifying against the bill. He stressed, there is an implicit bias in the legislation as proposed, which represents a condemnation, not only of the practice, but the motivation of psychiatrists and psychiatric hospitals. He stated, we are dealing with human suffering and part of that human suffering was witnessed in the testimony heard earlier today. There has been evidence of abuses, and he commented, no one here is positioning themselves to represent themselves as advocates for that kind of abuse. He pointed out to the committee, there are approximately 2.8 percent of Americans, who have serious mental illnesses, which warrant intensive psychiatric treatment. In many instances, as part of their psychiatric disease, they have a compromise of their ability to judge and do not have insight into the disorder and in rare occasions, there is a risk of danger from these people to themselves and to others.
Dr. Bittker explained, there are a number of steps in place, that TMMH takes to insure patients' rights are not being violated.
Their current practice is understanding that patients enter a psychiatric hospital with a great deal of ambivalence about their treatment. The staff of the hospital does whatever they can to secure the confidential information, regarding their treatment. Unfortunately, as one of the consequences of psychiatric treatment, they find there is a very rigorous review of that treatment by outside managed care agencies. Many times they see violations of confidentiality encouraged by those agencies. Health Care Financing Administration and the joint Commission of Accredition for Hospitals reviews what hospitals do, to insure there is a reasonable process and that the hospital is indeed treating patients and not imprisoning them. Whenever a physician does something that represents a violation of human rights, the physician is mandated to complete a denial of rights form and a copy would go the OPA. If there is an instance where a voluntary patient requires involuntary hospitalization, because of the physicians view of their dangerousness, TMMH has a policy that an independent psychiatrist reviews that instance within 24 hours. Also, there is an opportunity to present these cases to the court, and in his opinion, there is adequate opportunities within the court process now to deal with these abuses. He encouraged further involvement of the OPA but emphasized, if we put the burden of cost on medical care that is even greater than what currently exists, in his opinion, would make any psychiatric treatment of an in-patient nature prohibitive.
Chairman Rawson stated, the committee has to assume there is some truth to the stories told today, and therefore, we need to talk further about what additional safety valves we can have, what approach can we develop, so the persons who do not want to be held against their will, can have those rights protected.
Dr. Bittker commented, he welcomed prompter involvement of the OPA and concurred with Mr. Curry, in reference to getting through the court process sooner than 14 days.
Senator Neal questioned, how can a patient who has just a marriage problem, be placed in a locked up psychiatric ward, based on just a telephone interview with a clinician at the hospital. Harold. S. Orchow, M.D., Medical Director, Montevista Hospital, stated that in general, just a marital problem would not be the reason for that person to be admitted.
Bruce L. Tanenbaum, M.D., President, Northern Nevada Association of Psychiatric Physicians stated, if someone seeks treatment on a voluntary bases, after discussion with a clinician, who would discuss it with a doctor, and if it is felt appropriate to admit that person on a voluntary basis, that can be done over the telephone. In the case of an involuntary basis, that person must be seen by someone who can fill out involuntary commitment papers. On the commitment papers the hospital worker must state the reasons that already are covered in statute in Nevada, why this person is considered a potential danger to themself or others or unable to care for themselves. He strongly supports measures to help assure that any type of involuntary hospitalization is done adequately and done properly, with reasonable consideration of a person's dangerousness.
Senator Brown asked, have any of these people who have been admitted, attempted to commit suicide while they were in the facilities or within a matter of months after they were released. Dr. Bittker responded to Senator Brown and stated, people have attempted to hurt themselves within a psychiatric hospital. Because of the fact that within a psychiatric hospital there will be a high percentage of people who are disturbed, the hospital will have a high prevalence of that kind of acting out. He stated, TMH has had one completed suicide within the last 3 years.
Senator Brown commented, the OPA is not there to release people who the evidence shows, are in danger, if they get released. She stated, the main things in this bill is notice, and that hospital personnel have to turn over those requests to the OPA. Dr. Bittker responded, he does not feel that notification of the OPA is an unnecessary burden for the hospital. He suggested the time limit of 15 minutes may be a little short and cautions that wherever these kinds of burdens are seen, caution needs to be taken to not expose the public or private sector to excessive burdens, in terms of regulation and review. He concurred with Mr. Curry and welcomed any kind of monitoring that does not expose them to extensive costs or over regulation.
Dr. Orchow pointed out that only a judge can commit someone. This takes the action of a district court judge in a court room and explained the way the commitment procedure functions. It is termed an emergency admission in the statute, when a person comes into the hospital involuntarily and is a maximum hold of 72 hours. Within the 72 hours, the individual is to be thoroughly evaluated by whatever clinical staff is appropriate. At that point, a decision is made either to discharge the patient or to file the appropriate documents to request a commitment hearing. Between the time the documents are filed and the court hearing, the patient is examined by one or two psychiatrists, neither of whom has an interest in the case, to determine if that person is committable or not, and would so testify in the court room. If the conclusion of at least one of the psychiatrists, is that the patient is not committable, the patient is offered to stay voluntarily, if they choose to stay for continued treatment, or discharge if the patient demands to be discharged.
Dr. Orchow advised, Montevista Hospital has an internal advocate for patients. He explained, whether the person is admitted as an emergency or voluntarily, and becomes an emergency admission, that case is reviewed within 24 hours by the clinical director of the unit in which the patient is held. If the clinical director happens to be the psychiatrist, then the medical director reviews that case. If there is some controversy about appropriateness, that case is referred to the peer review committee of the medical staff for appropriate consideration and if necessary, discipline.
Chairman Rawson noted, in some states, they have a person that is employed by the state and suitably qualified, that will review all holds within 72 hours. He asked, Dr. Orchow, would he have any objections to the legislature establishing something similar to that. Dr. Orchow responded, he certainly would not.
Senator Brown expressed concern about the length of 72 hours, because in most job situations, the person would be terminated, if they did not show up for work for 3 days.
Dr. Tanenbaum stated, psychiatrists save peoples lives by committing them and assured the committee, there are hundreds of people on the street, who were committed and whose lives they have saved. He explained, the psychiatrists have to justify filing for a commitment. This filing has to hold up legally to the profession, to the law, to their colleagues and to themselves. He strongly requested the committee, if they pass any legislation, to make sure it is workable legislation and will fulfill the obligation to save people's lives.
Senator Brown responded to a comment from Senator O'Donnell and said, the representative of Charter Hospital did indicate to her willingness to work on amendments, but did not feel it was necessary to testify.
Gary Crews, Legislative Auditor, advised the committee a audit report was issued last year on the MHMR administrative offices. In that report, it was indicated that clients' rights were not being investigated by the Commission of Mental Health in the private facilities and they did make a recommendation, that procedures be developed and so on, to assure that rights are protected in the private facilities, as well as the state facilities. It was being done in the state facilities, but not in the private.
Jerry Zadny, Ph.D., Administrator, Mental Hygiene and Mental Retardation Division, State of Nevada, stated the commission has developed a procedure for reviewing denials of rights in private facilities, and will vote on that procedure and methods for disseminating the information out to private facilities at a meeting in Reno, June 25, 1993. He noted, if this bill were to pass in its present form, it would discourage private facilities from accepting a whole host of patients and could possibly close down several psychiatric hospitals. This would create a burden upon the state. The state is not funded to take care of these patients and would create a significant fiscal impact. He stated, there are a number of features to this bill that require further study.
Mr. Moore stated, we have to begin this inquiry knowing that any review of the records by itself, is insufficient. The records are made by people who have a financial interest in making the records look like the people are committable. He suggested that any interviews taken with the people, be tape recorded, so that a true independent review can be made at a later date. If a person gets a second opinion from a psychiatrist, who says the person does not need to be in the hospital, the person should be released within 10 or 15 minutes. He pointed out, the present law has a predisposition to keep people in the hospital. The people in psychiatric hospitals should be accorded the same sorts of rights that criminals are accorded, and be able to obtain that second psychiatric opinion. If the hospitals were legitimate in wanting to protect human rights, they would understand the need for the tape recordings and the need for independent review.
Chairman Rawson stated, he would take S.B. 533 into subcommittee and advised, anyone who has suggested amendments or who wishes to make comments a part of the record, may do so.
James L. Wadhams, Lobbyist, Nevada Hospital Association, stated from the testimony heard today, clearly there needs to be some work in this area and the Nevada Hospital Association is willing to sit down with the subcommittee and assist in working through this problem.
Chairman Rawson closed the hearing on S.B. 533.
Chairman Rawson opened the hearing on S.B. 527.
SENATE BILL 527: Authorizes board of trustees of school district to allow reading or posting of certain historical material in public schools.
Chairman Rawson explained, he authorized this bill to be drafted, because in the curriculum committees and organization, there have been cases where pieces of the Bill of Rights, Constitution or statements from presidents, have not been allowed without review. This would be a simple bill that would indicate that these are legitimate materials to be used in any classroom, if they pertain to the material at hand, and there would not have to be a special review of them. He stated, this is a self evident issue.
Brian Lusk, Student, Las Vegas, stated to the committee, he has had very little contact with at least half of these documents, in the public school system. He suggested that the Constitution of the United States be added and two changes be made to language (Exhibit H).
Sandy Coyle, Parent expressed her support of S.B. 527 and stated these historical materials should be included in her children's school curriculum.
Jeanne Simons, Parent testified in support of S.B. 527.
Chairman Rawson closed the hearing on S.B. 527.
Senator Brown pointed out there are certain religions that do not do the pledge of allegiance and she asked, if they attended a private school, would this bill affect them, if the legislature is encouraging them to post this. Chairman Rawson explained, this bill does not demand this to be done, it is simply authorizing someone to post these.
SENATOR O'DONNELL MOVED TO AMEND AND DO PASS S.B. 527.
SENATOR GLOMB SECONDED THE MOTION.
THE MOTION CARRIED. (SENATORS NEAL, COFFIN AND TOWNSEND WERE ABSENT FOR THE VOTE.)
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Chairman Rawson opened the hearing on Assembly Concurrent Resolution (A.C.R.) 37.
ASSEMBLY CONCURRENT RESOLUTION: Urges State Welfare Administrator to develop program to encourage certain recipients of Medicaid to participate in educational program on family planning.
Senator Diana M. Glomb, District No. 1, testified on behalf of Assemblywoman Vivian L. Freeman, who is the author of this resolution. She explained, on June 2, 1993, this committee heard testimony by Mila Florence, Administrator, Welfare Division, State of Nevada, who spoke in favor of A.C.R. 37. This legislation would urge the state welfare administer to develop a program to encourage Medicaid recipients to participate in educational and information programs regarding family planning. This resolution urges the administrator to continue to make further efforts, to be sure that this information and educational program is provided to Medicaid recipients.
Chairman Rawson closed the hearing on A.C.R. 37.
SENATOR BROWN MOVED TO ADOPT A.C.R. 37.
SENATOR GLOMB SECONDED THE MOTION.
THE MOTION FAILED, IT WILL BE RECONSIDERED AT A LATER TIME. (SENATOR O'DONNELL VOTED NO, SENATORS NEAL, COFFIN AND TOWNSEND WERE ABSENT FOR THE VOTE.)
* * * * *
Chairman Rawson excused Senator Glomb and the hearing went into subcommittee.
Chairman Rawson opened the hearing on S.B. 526 as a subcommittee.
SENATE BILL 526: Revises the manner in which interest must be paid to individual accounts in trust fund for child welfare.
John E. Adkins, Deputy Treasurer of Operations, State of Nevada, expressed the regrets of Bob Seale, State Treasurer who was not able to attend the hearing. He explained, the revised procedures in S.B. 526 provide for a more economical and efficient way of eliminating excess bank accounts and to create a small amount of revenue for the program, due to the efficient cash management of the trust fund. This is a small step in which the requirement of having each child's separate account in a separate bank account, has been eliminated. A position has been created, so these accounts can be grouped together in one account, maintained by the Department of Treasury, and the funds will be invested at a higher rate than could be received otherwise. The funds will be distributed to the trust fund, to the division and the division will then be able to utilize that funds for enhancement of the program. He stated, the division recommends section 5 be deleted, due to conflict with NRS provisions.
John Sarb, Administrator, Division of Child and Family Services, State of Nevada, explained, section 5 would prohibit his division from using court ordered support payments, as a credit to the cost of care. He checked with the Welfare Division, who previously administered this provision. They agreed, section 5 was confusing because it called into question, their practices around child support collections for mothers who are receiving Aid to Dependent Children. He spoke with Mr. Gary Crews, Legislative Auditor, who indicated to him, this was confusing language. He checked with Nancy Angres, Deputy Attorney General, and she could see no useful purpose for this section. He stated, this section is confusing and seems to be in contradiction with legislative intent expressed in section 3, as well as NRS 432.085, which specifically authorizes and requires the division to use these funds for cost of care.
Mr. Crews stated support of the concept. He explained, when the audit was done, 61 bank accounts were identified, which would be an administrative nightmare to handle. This would simplify the process and address the auditor's concerns.
Senator O'Donnell referred to a misappropriation of funds in the prison system, in dealing with the same sort of system. He asked could children lose their funding.
Mr. Crews stated, there is more possibility of misappropriation of funds when there are more accounts. He stated, consolidating the funds will simplify the problem and added, this is not the same situation as the prison.
Senator O'Donnell asked for clarification on interest being paid.
Mr. Adkins stated, the language that would be used, is similar to the language used by the public works board, in that it determines a definite amount that entitles the children to at least the same amount they would receive, if they have invested it into a bank account on their own. These monies are consolidated into the General Fund investment pool, which usually generates at least twice what that rate would be in individual accounts.
Chairman Rawson asked, if we strike section 5, this money will be used for their support, so they may not receive this money when their foster care is over. Mr. Adkins responded yes, the interest will be added to their account, their account will be charged with the charges and if there is any remaining, they will have it.
Senator O'Donnell asked, if these accounts are aggregated into a fund, this money is invested and would get double the return of what the individual accounts would make, where does the difference go. Mr. Adkins responded, that goes to the enhancement of the children's program, and remains in the trust fund, used by the division.
Chairman Rawson closed the hearing on S.B. 526.
There being no further business, Chairman Rawson adjourned the meeting at 4:55 p.m.
RESPECTFULLY SUBMITTED:
Judy Alexander,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE:
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Senate Committee on Human Resources and Facilities
June 14, 1993
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